Wednesday, 6 February 2013

The Francis Report shows the tragic
consequences when patients and carers do not have a voice and are not heard.
Improving systems, management and inspection is part of the answer. But this
does not address the lack of democratic accountability and scrutiny in health
matters.

A Parliament for Health could
strengthen democratic scrutiny and accountability of all provision and
legislation that affects health by creating a representative forum on health
matters within our system of Parliament rather than Whitehall or the NHS. It would
consist of representatives of stakeholders concerned with all aspects of health,
including patient groups, staff, researchers, civil society organisations and
elected representatives from other tiers of government, including parish and local
councillors and MEPs. It could be co-chaired by back bench members of
parliament. In time it could have directly elected ‘Health Representatives’ and
be part of to a new kind of second chamber, to draw a wider range of experience
and expertise into the political process. But MPs could set up a “Health Parliament”
or Forum as an extension of the Select Committee to strengthen their oversight
of health matters. A Parliament for Health could have
statutory rights to discuss all legislation that impacts on their health, conduct
investigations into the implementation of policy and report directly to the
House of Commons through their Member of Parliament (the Co-Chairs).

It would have the following tasks:

Propose national priorities in health, for the NHS as well as public health;

Hold the NHS Commissioning Board, Monitor and other strategic health bodies to account on behalf of Parliament (which should have the final say);

Oversee and hear reports from our representatives on the World Health Organisation, EU Council of Health Ministers, the Food and Agricultural Organisation (FAO) and other international bodies influencing health policy;

Promote dialogue round important issues, such as the Francis Report, the Bristol Royal Infirmary inquiry etc;

Recommend priorities for research and development in health policy and provision;

Organise public consultation on proposals by the Government, taking consultation on major health matters from the NHS and Whitehall;

Pre-legislative scrutiny of proposed bills before they are presented to the Commons, to draw attention to health implications

Scrutinise and revise legislation through a “public reading stage” before the second reading in Parliament;

Contribute to consensus building, where appropriate;

Advise and assist on policy implementation;

Monitor implementation of all policies that affect health;

Review and evaluate the impact of legislation.

This is a big and important agenda.
Failures in the NHS are symptoms that this has not been done by Parliament and the lack of proper democratic oversight and
accountability. Simply putting “patients in control” through market mechanisms
will not solve these strategic problems. If greater choice, commissioning and markets
have a role, then the rules and political oversight are even more important. The
House of Commons simply does not have the capacity to address these issues,
even if MPs had the knowledge and experience to do so.

A Parliament for Health (or National Health
Forum) would dramatically increase the knowledge and experience to
inform health policy-making. It could work through a mixture of open public
meetings, online forums and a standing body of stakeholder representatives.
Members could be elected through democratic associations of civil society, neighbourhood forums the
professions and patients, thus strengthening the democratic processes across society. It could
be supported by an all-party Parliamentary Commission and run by a new
department of the House of Commons Service, not Whitehall or the NHS.The following diagram shows the relationship between a National HealthForum, Parliament and the NHS: it is telling that the original, offical diagram had the public and patients at the bottom - the kind of perspective which led to the outcomes at Mid-Staffs and Cardiff University Hospital.

Developing Democracy through Citizens’
Policy Forums

A Parliament for Health could develop
a model for “Citizens’
Policy Forums” to improve democratic government by strengthening public
participation and connecting civil society with the political process in new
ways, using interactive meetings, the internet and imaginative forms of active
participation, round the issues people care about. They would be a form of
practical political education, through which people learn how to contribute
their experience and expertise about health to the policy-making process.

Regular, statutory Citizens’ Policy Forums could
replace ad hoc consultative bodies, strategic partnerships and advisory groups
in Whitehall with a more open, accountable and interactive means of involving
civil society in politics between elections. They would draw a much wider range
of people into the Parliamentary process, contributing to the scrutiny of
legislation and Government from the perspective of broad policy areas, rather
than a party political perspective. Members of Policy Forums would be obvious
candidates for an elected Senate. As a new kind of parliamentary chamber, Forums
would also create new routes into Parliament and widen the pool of potential
members of Government while strengthening the primacy of the Commons.

Instead of being the last western
country to have an elected second chamber, Britain could be the first to create
a new kind of parliamentary process which enables citizens to take a more
active part in politics between elections through the internet, participatory
community meetings and the democratic associations of civil society.

Civil society organisations should
take the initiative and create a Health Policy Forums to scrutinise and challenge
Government, because the cost of not taking into account the breadth of
experience and interests in health is too high.

We need to look at how our democracy deals with health issues in response to the Francis Report into the terrible failures of care at
Mid-StaffordshireHospital. This blog looks are why we need a 'Parliament for Health'; the next blog looks at what it would do and how it would work. The Francis Report, Ann Clwyd’s
shocking description of her husband’s death “like a battery hen” in
Cardiff’s University Hospital and the“hundreds and hundreds” who have writtento herare just the latest horror stories about failures in our health
services. While every day thousands of patients get wonderful care and 90% are
satisfied with their experience, too many people have a bad or even
terminal experience through mal-treatment, neglect or hospital acquired
infections.But our problems in health
are much wider than issues of leadership, management and organisational culture of the NHS. How services are run is just the most visible part of health care, which includes the way we look after our
own health, how we care for each other and the health effects of work as well as the
food, drink and tobacco industries. Each of these present problems which cost many more lives and misery than mis-management at Mid-Staffordshire. The
direct cost of health services are also a critical issue. Direct cost through taxes is about £1,700 per person per year, £106bn, and indirect
cost of ill-health are about £100bn a yearor another £1,600 each. Add to that the soaring cost of personal care, the lack of support for carers and
the value provided by six million unpaid carers (variously valued at£23bnto £119bn, and we have a very complex picture for the state of
health.

Many urgent issues need to be dealt with in our health
services, some of which are strategic and many of which are local, in an area or
institution. But it is decisions on strategic issues which create the framework for the whole system and set the conditions which allow tragedies like
Staffordshire andCardiff’s University Hospital to occur. These
strategic decisions are political, about the priorities, structure and funding
for every aspect of health, including the balance between prevention and cure, between
personal and collective responsibility, or between environmental and medical
factors.

Health is one of many areas
where our political system has failed for decades and Governments have kept
people powerless to do much about it, as the experience of whistle blowers in the health service shows. Our centrally run health service gives
Ministers the illusion of control, so we have had decades of ‘start-stop and
start again’ health reforms which make it very difficult for people themselves to
take part in creating better provision for health.

Since
1974 successive Governments have grappled with the complexity of
preventative health, primary care, hospitals, nursing, social care, mental
health, medical effectiveness, an aging population, rising costs and a myriad issues
that affect our well-being. The NHS has been almost
continuously reorganised in pursuit of better patient care, greater clinical
leadership, devolved responsibility and less bureaucracy. The objectives have
been largely consistent, but successive Governments have taken us on an
expensive rollercoaster, plunging and twisting through GP Fundholding, Care in
the Community, Family Practitioner Committees, Primary Care Groups, Primary
Care Trusts (PCTs) and now Clinical Commissioning Groups (CCGs). While some interest groups (GPs, consultants, dentists) have done
well out of this mystery tour, many others have not, the public is losing
out, and the cost is enormous.

The
Francis Report will be added to the shelf of recommendations and another transitory Government will give the NHS another shake. Some improvements may occur, if we're lucky, but wider problems will persist and some will get worse because political attention
and resource is elsewhere: when you turn the spotlight on one problem, the rest
are left in the dark. Some things may get better due to lack of
interference, while others get worse through neglect.

Most battles over health reform
are among politicians and the professionals. The public is rarely involved in
difficult debates about how to balance priorities between prevention, primary
care, social care, hospitals or our £9
billion annual drugs bill £8.81bn in 2011,
except when mobilised to fight over a particular hospital, treatment or
reorganisation.

Whatever the rhetoric, the
public only has a token voice in how we look after health as a society and how services are provided. Formal
participation has been channelled through a succession of weak bodies, from
Community Health Councils (1974-2003), Patient Forums (2004-8), LINks (Local
Health Involvement Networks, 2008-2012) and from October 2012 HealthWatch.
There is a tiny amount public participation through representation on health
trusts, and more active involvement through fundraising, self-help groups,
volunteering and charitable provision such as hospices, but these are largely
excluded from decision-making. In many areas the voluntary sector, PCTs or
local councils have set up forums for health and social care, which can comment on
decisions but are powerless.

The 1974 NHS reorganisation also
created joint consultative committees (JCCs) to promote joint planning between
health and local authorities, but they did not have the power to be effective.
Now the Government is setting up local Health and Well-Being Boards which will
face similar challenges with even greater financial pressures than those which
undermined the JCCs in 1974 (see Health and wellbeing boards: system leaders or talking shops?).When the Coalition Government
ran into political difficulty over its health service reforms, it set up the NHS Future Forum, a group of health experts led by GP Professor Steve Field, but barely
two or three of its 55 members represented patients or the public.It listened to more than 11,000 people face
to face at over 300 events as well as engaging with people online, but then
public involvement stopped. Then it is set up the
Nursing and Care
Quality Forumfor another burst of consultation.

But
neither Government nor Parliament have the time or capacity to give health
matters the sustained scrutiny they need, or to develop the political framework
which balances all the different issues and interests involved in health and
well-being. What we need, therefore, is a “Parliament for Health” to grapple
with the political issues in public. A Parliament for Health could have directly
elected representatives (MHPs) or indirectly elected from local Health and
Well-Being Boards and other stakeholder groups, with a majority of from civil
society, to ensure that the people are in charge of the professionals, as it
should be in a democracy.

If
the NHS were a country, its£106bn budgetwould make it the55th largestcountry in the world, about the size of New Zealand, Hungary or Vietnam in
terms of GDP.
It would have a seat at the UN – and it has one in the World Health Organisation, WHO, and its civil
service, the NHS Commissioning Board, Monitor and other bodies, would
be answerable to citizens through Parliament.

If
all health-related policy and legislation had been systematically scrutinised
by “Health Parliament”, with a majority of representatives from patients and
the public, feeding into the democratic processes of Parliament, Governments would not have been able to lurch from one
reorganisation to another. Sustained public dialogue between interest groups
involved in health, including the public, is more likely to have created better
patient care, greater clinical leadership, devolved responsibility, less
bureaucracy and greater emphasis on public health, health promotion and
well-being. Problems like those at Staffordshire, Cardiff’s
University Hospital, Alder Hey, the Bristol Royal Infirmary, Great Ormond Street and elsewhwereare much more likely
to have been raised by “Health MPs”, listened to and dealt with than the regulators who have clearly failed.

We
do not need more inspectors – the most likely response to the Francis Report. David Cameron's proposal for a chief health inspector may be a useful lightning conductor for failings in future, but what will make most difference are the hundreds of thousands of inspectors who go into the NHS every day -
patients, their families and frontline staff. They are also the people who will make most difference to the health of the nation, in homes, workplaces, shops and streets as much as in doctors surgeries and hospital wards. We are the people who determine what happens to our health, and we need more democratic accountability
from bottom to top to make sure that health services and support meet people's needs with care.